Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
William Harvey Research Institute MSc in Forensic Medical Sciences
Unintentional Asphyxiation Deaths in Adolescents: Autoerotic asphyxia and asphyxial games as part of the same syndrome Forensic Pathology
Andrés Rodríguez Zorro Student ID: 100511332 Monday, September 3th, 2012
Supervisor: Professor Peter Vanezis
Word count: 19.575
Dissertation submitted to Queen Mary University of London in partial Fulfillment of the requirements for the Master of Science degree
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
CONTENTS
LISTE OF TABLES 3
ACKNOWLEDGMENTS 4
1.0 ABSTRACT 5
2.0 METHOD OF UNDERTAKING THE LITERATURE SEARCH 6
3.0 INTRODUCTION 7
3.1 Definition of autoerotic asphyxia 7 3.2 Definition of asphyxial games 8 3.3 History 9 3.4 Neurophysiology of neck compression asphyxias 12 3.5 Characteristics of autoerotic asphyxiation 16 3.6 Characteristics of asphyxial games 18 3.7 Aims 21
4.0 RESULTS
4.1 Who plays asphyxial games 23 4.2 Who are the victims of autoerotic asphyxia in general population 28 4.3 Who are the victims of autoerotic asphyxiation in adolescence 32 4.4 Who are the victims of asphyxial games 36 4.5 Comparative analysis of asphyxial games and autoerotic asphyxia 41
5.0 DISCUSSION
5.1 Etiologic theories 44 5.2 Sociological view: the ordeal or radical confrontation with death 46 5.3 Confrontation with risk in adolescence 48 5.4 Childhood rope syndrome 51 5.5 Part of same syndrome 52 5.6 Risk of death 61 5.7 Limitations 63 5.8 Recommendations 65
6.0 REFERENCES 67
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
LIST OF TABLES
Table 1 : Neurophysiology: agonal sequences in hanging 14
Table 2 : Outcome with various techniques of asphyxial games 21
Table 3 : Participation rate of students in asphyxial games 27
Table 4 : Key characteristics of asphyxial games in living participants 28
Table 5 : Risk factors linked to living players of asphyxial games 28
Table 6 : Series of fatal cases of autoerotic asphyxia in general population 30
Table 7 : Key characteristics of victims of autoerotic asphyxia in general population 32
Table 8 : Fatal cases of autoerotic asphyxia in adolescents reported in literature 34
Table 9: Key characteristics of victims of autoerotic asphyxia in adolescents 35
Table 10 : Fatal cases of asphyxial games reported in literature 38
Table 11 : Key characteristics of victims of asphyxial games 41
Table 12 : Comparison between fatal cases of autoerotic asphyxia and asphyxial games 43
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
Acknowledgments:
My sincere thanks to Professor Peter Vanezis for his commitment and dedication as a teacher in each of his presentations during the program, for sharing his experience and knowledge in the practice of autopsies and for his guidance in addressing the subject of this dissertation. It is an honor to have been a pupil of the highest authority in the field of forensic pathology in the UK. Thanks to the entire faculty of the Masters program and at Barts and the London School of Medicine and Dentistry; to life for giving me a second chance and allowing me to grow personally, academically and professionally during my year at fascinating London.
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
1.0 ABSTRACT
OBJECTIVES: Unintentional asphyxia among preadolescents and adolescents by compression of the neck and other means of inducing hypoxia / anoxia in order to get exhilarating effects are not new or uncommon behaviors and can lead to death by accident. Medical science has described autoerotic asphyxiation and more recently asphyxial games “choking games” as different entities. This study addresses both behaviors to understand the characteristics of how these practices are presented as well as the risks factors to them in order to determine if there are substantial differences between the two practices, or if instead they are related behaviors. Accurate knowledge of these behaviors based on scientific evidence will facilitate the understanding of the etiology and manifested features and facilitate the implementation of preventive measures to avoid such deaths.
METHODS : A retrospective study of fatal cases published in recognized scientific journal articles of both autoerotic asphyxiation and choking game behaviors in the adolescent population was made. Articles on sociology, psychoanalysis and psychiatry as well as studies previously published case series and epidemiological studies to assess student population etiological factors and risk factors associated with behaviors were included in this review. Features of both behaviors, such as prevalence, age distribution, gender, type of asphyxia and place of occurrence are presented.
RESULTS : The results are consistent in all variables analyzed for both behaviors. Most practitioners are men. Cases of both behaviors in preadolescence show a tendency to increase with age. The most frequent type of asphyxia identified was hanging conducted in private quarters. Psychiatric and psychoanalytic literature identifies common elements between male castration complex, failed oral psychosexual development and the practice of asphyxia in its integration with sociological theories of risk and confrontation ordeal in adolescence. The review of epidemiological studies reveals common elements in the development of both practices in terms of risk factors.
CONCLUSIONS: The evidence suggests a link between both practices and allows to theorize that they are part of the same syndrome. Integrating psychoanalytic and sociological concepts as well as the risk factors suggests a linear sequential model of development in four stages: childhood syndrome rope, asphyxial games associated to masturbation, Adolescent autoerotic asphyxia and Adult Autoerotic Asphyxia fetishist / bondage Syndrome. Death is explained in each of the stages as failed physiological and emotional adaptation mechanisms. It is important to disseminate knowledge of these practices among health professionals and further studies should be carried out in regarding deaths by hanging in children and adolescents.
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
2.0 METHOD OF UNDERTAKING THE LITERATURE SEARCH
The analyses were based on an extensive search of electronic databases available through the Queen Mary University of London and British Library. The databases included both: medical and psychological publications: PubMed (Medline), PsychINFO, PsycARTICLES, PsycCRITIQUES, PsycEXTRA and the Psychology and behavioral Sciences Collection.
The terms used for the search were: choking game, asphyxial games, self strangulation games, sexual asphyxia, autoerotic asphyxia, autoerotic asphyxiation, autoerotic fatalities, autoerotic death, hypoxiphilia, asphyxiophilia, sexual asphyxia syndrome, adolescent sexual asphyxia, adolescent asphyxia, unintentional asphyxia, voluntary asphyxia.
All published studies and articles available were reviewed and the papers considered for the revision were: 1. Studies of series of fatal cases of autoerotic asphyxia in general population 2. Case reports of voluntary asphyxia deaths in late infants, preadolescents and adolescents (age between 7 and 19 years). 3. Studies of both: asphyxial games and autoerotic asphyxia in preadolescents and adolescents. Other autoerotic deaths (non asphyxial) were excluded. 4. Peer reviewed journals and articles 5. Publications in English, French or Spanish. Other languages were excluded. 6. Articles published prior to 1990 were excluded to ensure that current and salient data were presented (with the exception of some early influential papers).
Relevant forensic pathology, psychology, sociology, epidemiology and psychoanalytic literature related with autoerotic asphyxia, asphyxial games and hypoxiphilia were all considered.
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Unintentional Asphyxial Deaths in Adolescence Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome Andrés Rodríguez Zorro
3.0 INTRODUCTION
3.1 DEFINITION OF AUTOEROTIC ASPHYXIA
Autoerotic deaths have been defined by Byard 1, as “accidental deaths occurring during individual, usually solitary, sexual activity in which a device, apparatus, or prop used to enhance the sexual stimulation of the deceased in some way caused unintentional death”.
Typical methods of autoerotic activity leading to death are mostly asphyxia maneuvers: hanging, ligature strangulation, plastic bag, chemical substances, or a combination of these. Other asphyxia methods includes: chest compression, positional asphyxia and drowning. Atypical methods include electrocution, overdressing/body wrapping, foreign-body insertion, and other miscellaneous methods 2.
Autoerotic asphyxiation syndrome was described by Resnik 3 in 1973 as "repetitive erotic hanging", also known as asphyxiophilia or hypoxyphilia. It is a paraphilia in which sexual arousal and achieving orgasm depend on self-strangulation and suffocation, leading to a loss of consciousness but without actually becoming unconscious. Compression of the neck and choking sensation heightens the feeling of pleasure during masturbation. The interference of oxygen to the brain causes hypoxia that explains the effect.
Hypoxiphilia is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) - American Psychiatric Association 2000, as a paraphilia, a subtype of sexual masochism, not otherwise specified. It is characterized as a “particularly dangerous form of sexual masochism [that] involves sexual arousal by oxygen deprivation obtained by means of chest compression, noose ligature, plastic bag, mask or chemical”. 4
This behavior also appears well described in ICD-10 Mental and Behavioral Classification of Disorders (World Health Organization, 1992) independently of
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sadomasochism, classified under the category "Other Disorders of Sexual Preference" and defined as: "use of strangulation or anoxia for intensifying pleasure sexual”. 5
The syndrome has been recognized throughout history by various cultures but medical literature did not provide a description until 1856 and 1866 5. Most of the literature related to it only appeared in forensic pathology publications and was virtually unknown to much of the medical community in hospitals.
There are few references to the etiology of these practices and it is unclear how often adolescents incur in the practice. Most publications and literature only mention that the syndrome is more common in young men, but only a few addresses the syndrome in adolescents.
It is estimated that between 500 to 1000 deaths per year are related to autoerotic deaths in the United States 6. In Canada, Sauvageau 7 estimates an incidence of 0.2 to 0.5 cases per million inhabitants per year, showing a very low incidence for this type of practice. However, these figures should be interpreted with caution given that most cases are not due to fatal asphyxia. They are carried out in secret as a form of sexual experimentation (some "different" sexual behaviors are seen as a taboo even by society) and are not described to the medical personnel who assist at emergency services. Additionally, in fatal cases, these deaths are mistakenly labeled as "suicide" by authorities who remove evidence from the body, forensic pathologist and even by the family itself.
3.2 DEFINITION OF ASPHYXIAL GAMES
Asphyxiation games of self strangulation as practiced by preteens and teens, called "choking games" in the literature, are another form of voluntary suffocation which is known to have increased in the last decade mainly in the school population. A recent report by the Center for Disease Control and Prevention (CDC) in Atlanta defines this behavior as "self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia”. 8 The mechanisms
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used mainly include compression of neck vessels manually or with ligatures to reach a state of euphoria and other effects linked to hypoxia. There are variations of this practice consisting of vagal stimulation using the Heimlich maneuver (compression of the carotid sinus) or maneuvers that incite hyperventilation with subsequent chest compression to induce presyncope. These sensations are perceived as pleasurable and lead to repetition.
These games bear suggestive names: "Black Hole", “Black Out”, “Flatlining”, “Funky Chicken”, “Space Monkey”, “Suffocation Roulette”, “Gasp”, “Tingling and Knock Out”. French calls them "reve blue" (blue dream), “reve indien” (Indian dream), “jeu du cosmos” (cosmos game), “jeu des poumons” (lungs game) and the best known of all is “jeu du foulard” (scarf game). Spanish cites “juego de la asfixia” (asphyxial game) o “juego del desmayo” (fainting game). Some young people even refer to them as the "drug of good children", in allusion to the pleasurable effects and excitement produced by some drugs.
3.3 HISTORY
Examples of the association between asphyxia, sexual pleasure and excitement have been described in different cultures and different historical periods. Anthropologists have reported that Eskimo children hang themselves during certain types of games in which they seem to mimic asphyxial behavior of adults during intercourse 3. Similarly, young people of ethnic Yahgans in Tierra del Fuego in southern Chile use ligatures to induce partial strangulation and excitement while describing having seen bright colors. 9 Moreover the children of the Shoshone-Bannock ethnicity in Idaho, United States, play games like "smoke out", "red out" and "hang up" which are essentially suffocation and strangulation games. 10
A stone sculpture at the Museum of Anthropology in Mexico City shows a male teenager with a tight band around the neck, while his penis is erect. The museum notes that the sculpture represents a teen phallic cult and corresponds to the Mayan culture, about 1000 AD during the transition from the Late Classic period and the Early Post
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classic. It is known that the Maya believed that the souls of individuals who hung themselves went straight to paradise where Ixtab, the goddess of the hanged, received them. The representation of the Maya goddess in manuscripts shows her in a kneeling position with a rope around the neck, ankles tied and nipples visibly erect.
In the literature the autoerotic maneuvers have been described since the 1600s. In those days sexual asphyxia was used as a technique to cure impotence. 3. The Marquis de Sade places the practice of erotic hanging in ancient Celtic culture. His description is clearly referenced in his novel “Justine” published in France (1791). 11
Herman Melville describes the eroticization of hanging in his novel of strong homoerotic content "Billy Budd" published in 1924 10 . Heinz Ewers cites the legend of the origin of the mandragora calling to mind the semen produced during the hanging in "Alraune". 12 In the tragicomedy in two acts by Thomas Beckett "Waiting for Godot", published in 1952, Vladimir and Estragon discuss ways to alleviate boredom using stimulants by hanging himself while waiting for Godot. 13 Finally in the fictional novel by Thomas Harris "Hannibal", published in 1999 and made into a film in 2001, the character Mason Verger practiced autoerotic asphyxia by hanging while Hannibal Lecter makes him inhale a “popper” (amyl nitrite) and suggests cutting his face with a piece of glass, then feeding the pieces of meat to the dogs. 14
For centuries it has been well known that prostitutes were aware of sexual asphyxia. In England there were brothels with a reputation for choking which were used to enhance the pleasure of their customers. The "Hanged Men's Club" during the Victorian era in London was recognized because of the practice of controlled hangings to satisfy the sexual fantasies of their clients. 15 Also in London the cases of the deaths of Huguenot writer Peter Anthony Motteux in 1798, 16 and Czech musician Frantiseck Koczwara author of "The Battle of Prague" in 1791 17 have been connected to practices of autoerotic asphyxiation. Among more recent cases there are those of the Australian Michael Hutchence, renowned vocalist of rock group INXS, in Sydney 1997 18 and that of the American actor David Carradine in Bangkok in 2009. 19
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In the medical literature the first reference in English (Ryan, 1836) 20 gives examples of suffocation "to excite the venereal appetite", and in 1856 the French psychiatrist DeBoismont described the association between hanging, erection and ejaculation. He described the interesting case of a boy of 12 years who was found suspended by a rope tied to a rack and feet flat on the verge of a manger. His father cut the cord quickly and was able to revive him. The boy later said that he had no desire to end his life but he had felt an irresistible urge to carry out the practice of risk. 21
In 1936 Ellis described the "urge to strangle the object of sexual desire" and drew attention to the fact that some young individuals obtain pleasure from fantasizing about being strangled. 22 In 1947 the following case report in the text Keith Simpson's Forensic Medicine: "A naked youth found in a lavatory was half hanging off the edge of the seat, the turgid penis and sperm dribbling from the neck suspended by a rope to the inlet pipe of the cistern above. Several front pages of pictures of nudes were laid out in a half ring in front of him on the floor. Death was due to vagal inhibition and must have taken place suddenly, without warning. These cases must not be mistaken for suicides; they are accidental deaths ". 23
From the second half of the twentieth century there are multiple reports of cases of deaths related to autoerotic asphyxiation in adolescents mainly published in forensic pathology. In 1953, Stearns 9, published a review of 97 suicides of young people and found that up to 25% of these corresponded to apparent unmotivated suicide, accidental deaths and / or sexual hanging. The relationship between transvestism and hanging was later explored by Shankel and Carr (1956) 24 , in the first case presentation of a live practitioner sexual asphyxia to appear in the literature was a teenager. Rosenblum 25 mentioned for first time the term “Adolescent Sexual Asphyxia Syndrome” and cited three case reports [Edmonton, (1972) 26 , Herman, (1974) 27 , Litman and Swearinger, (1972) 28 ] of adolescents who survived a hanging. Of these three case reports presented by Edmonson one shows a teenager whose behavior was clearly sexual. Resnick, 3 theorized to quantify eroticized, repetitive hangings as a syndrome. He listed 10 features
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including being adolescent or young men. This finding was supported by Hazelwood and colleagues (1983) in an analysis of 132 postmortem cases. 6.
Most current literature references related to this topic are published in journals of forensic pathology and psychiatry but did not emphasis in adolescents. Due to the limited distribution and availability of these items, the subject is unknown and misunderstood by much of the medical community and society.
3.4 NEUROPHYSIOLOGY OF NECK COMPRESSION ASPHYXIAS
According to what Resnick 3 postulated in 1972, constriction of the neck:
1. Disrupts the blood flow that supplies oxygen to the brain
2. Increases retention of carbon monoxide
Both hypoxia and hypercapnia affect some particularly sensitive nuclei of the brainstem and produce a state of semialucinosis accompanied by a lucid and placid feeling of light-headedness that enhances masturbation. Reinforcing the above, he mentions that physiologically ejaculatory pleasure is accompanied by breath holding and contraction of the muscles of the neck.
The most common mechanism used in autoerotic practices according to the literature reviewed is the compression of the neck of which the most common is hanging. 2 The immediate consequence of bilateral compression of the vascular structures of the neck over the carotid sinus is primarily a loss of consciousness due to cerebral hypoxia. Compression can be performed by placing a ligature around the neck, which compresses the vascular structures (arterial and venous) and is designed to give the person control over the pressure and thus provides a mechanism to stop or release the pressure. Other variables may be manual or ligature strangulation produced by a second person. Transient cerebral hypoxia combined with physical impotence and the fact of putting oneself at risk to the limit of death increases sexual gratification. Yet this method reduces
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self-control and impairs judgment, which may result in accidental death because of the victim's inability to operate the rescue mechanism provided.
Multiple studies show that pressures as low as seven pounds is sufficient to induce unconsciousness quickly: under 15 seconds in some cases. Sauvageau et al (2011) 29 reviewed fourteen cases of videotaped hangings: nine autoerotic accidents, four suicides and one homicide. With time 0 representing the start of the hanging, he observed a rapid loss of consciousness (Average 10 ± 3 seconds) in all cases. Loss of consciousness was thoroughly evaluated through observation of the face in association with body tone.
The next event documented reported seizures after loss of consciousness in all cases (Average 14 ± 3 seconds in all cases). In the following seconds (Average 19± 5 seconds), decerebration rigidity was observed, with full extension of the upper and lower extremities, extension of the hips and knees, adduction of the legs, internal rotation of the shoulders extension of the elbows, hyperpronation of the distal parts of the upper limbs, with finger extension at the metacarpophalangeal joints and flexion of the interphalangeal joints.
After the decerebrate rigidity, the author describes two phases of decorticate rigidity. This postural attitude is characterized by marked extensor rigidity of the legs (the same to the one observed in decerebrate rigidity), but combined with rigidity of the flexors of the arms: the arms appears flexed and bend on the chest, with the hands clenched into fists. The first phase occurs relatively rapid (beginning around 21 seconds, Average: 40 ± 16 seconds). It was followed by a second and sometimes a third phase of decorticate rigidity.
The apparent loss of muscle tone varied between 1 min 38 sec and 2 min 45 sec (average: 1 minute 17 seconds ± 25 seconds) with a last isolated muscle movement occurring between 2 minutes 15 seconds and 4 minutes 12 seconds. For respiratory response, the following sequence was observed: deep rhythmic abdominal breathing attempts with contraction of the diaphragm begin between 13 seconds and 32 seconds
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(average 19± 5 seconds) and stopped between 1 minute 2 seconds and 2 minutes 37 seconds (average, 1 minute 51 seconds ± 30 seconds). All results are shown in table 1.
Table 1. Neurophysiology. Agonal sequence in Hanging. From: Sauvageau et al. Agonal sequences in 14 filmed hangings with comments of the role of the type of suspension, ischemic habituation, and ethanol intoxication on timing of agonal responses. Am J Forensic Med Pathol . 2011;32(2):104-107 Average Time
Loss of consciousness 10 ± 3 s Convulsions 14 ± 3 s Decerebrate rigidity 19 ± 5 s
Stat of deep rhythmic abdominal 19 ± 5 s Respiratory movements Decorticate rigidity 38 ± 15 s Loss of muscle tone 1 min 17 s ± 25 s End of deep rhythmic abdominal 1 min 51 s ± 30 s Respiratory movements Last muscle movement 4 min 12 s ± 2 min 29 s
The findings of Sauvageau et al 29-30 are consistent with those described by Rossen et al. (1943) 31 who conducted a study with 85 male volunteers between the ages of 17 and 31 who were asphyxiated with an inflatable sleeve on the neck. Loss of consciousness was documented in ranges of 5 to 11 sec.
Other less common forms of autoerotic asphyxiation deaths are in order of frequency: suffocation by placing a bag over the head, chest compression and /or abdomen and chemical asphyxiation and/or suffocation by displacement (inhalation of aerosols, anesthetics, or chemical vapors) 2. There are reported cases of positional asphyxia. Almost anecdotally, Sauvageau 32 describes a case of autoerotic drowning of a 25 year old in a rare case that occurred in a lake involving restriction of the body and the use of homemade diving contraption. In all cases the
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physiology is very similar. Both hypoxia and hypercapnia produce a state of exhilaration and induce a short but intense lucid semialucinosis that coupled with the sexual fantasy increase sexual pleasure during masturbation.
In asphyxial games the most widely used mechanism is the compression of neck vessels: manual strangulation or with clothes when practiced with a partner or hanging when the individual practices clandestinely. Some variables to the game add prior hyperventilation which involves hypocapnia.
Once the physiology of hypoxia is understood it is no surprise to learn that the use of substances such as amyl nitrate (poppers), nitrous oxide and other inhalants such as 1,1-difluoroethane (HFC-152a) is related to sexual activity. The intake method of the first substance is by way of an inhaler that induces metahemoglobinemia and hence low oxygen supply to the brain. It has historically been associated as a sexual facilitator or "aphrodisiac" and is commonly used among prostitutes and homosexuals. During the 70 and 80's and times it was commonly used as a club drug because of the effects of intense lucid semialucinosis secondary to hypoxia which together with music and other visual stimuli is perceived as extremely pleasurable. In fact, in the literature reviewed, Bungardt and Potsch 33 , reported a case of autoerotic asphyxiation related to the use of amyl nitrate in Germany in 2003. In the case of nitrous oxide or "laughing gas", a substance also used recreationally to obtain euphoria effects, the practice of inhaling the gas inside a rubber pump and repeatedly reinhaling content is common in students. 34 This use clearly induces hypoxia and hypercapnia accompanied by hallucinosis. Sakai 35 reports in recent literature a case in Japan of the autoerotic death of a 41 year old adult by inhalation of 1,1-difluoroethane (HFC-152a), a known spray cleaner that produces euphoria. In the series of cases viewed, autoerotic asphyxiation by other gases such as methane, propane, solvents and anesthetics is frequently described.
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3.5 CHARACTERISTICS OF AUTOEROTIC ASPHYXIATION
According to Byard (1991), autoerotic deaths denotes an unanticipated death that results while the subject is engaged in solo sexual activity and the arousal- enhancing device designed to rescue participants fails. 1 Autoerotic asphyxia deaths constitute de vast majority of these cases. The most frequently encountered method was asphyxia by hanging or ligature. 2
Hazelwood 6 describes four mechanisms that interact or contributes in varying degrees to an autoerotic asphyxia: (1) neck compression, (2) oxygen deprivation, (3) airway obstruction and (4) chest compression. Participants of autoerotic asphyxia use combination of these components with intention to heighten sexual arousal. Participants tend to repeat de practice compulsively and in a solitary and clandestine context which may result in a loss of control of self rescue mechanism and accidental death.
The self –rescue device is designed to provide the participant a fail-safe capability to free himself from the autoerotic act prior to a fatal outcome. The mechanisms vary from a simple maneuver of standing erect to control neck compression to complex ligatures between limbs and neck controlled by body movements. Shields et al (2005) 36 identified a slipknot as the most common rescue device in cases of autoerotic deaths by ligature asphyxia. In a study of 16 cases, slipknot had been used by 84.6% of the victims who still had the ligature about the neck at autopsy.
The incidence of autoerotic asphyxias demonstrates particular characteristics. Resnick (1972) listed 10 features including: (1) an adolescent or young male; (2) ropes, belts and binding materials so that the constriction of the neck can be controlled voluntary (3) evidence of masturbation; (4) partial or complete nudity; (5) usually a solitary act; (6) repetitive behavior designed to produce no visible
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marks; (7) no apparent wish to die; (8) presence of erotic literature. Resnick mentioned other two elements less frequent: (9) binding of body/genital/extremities and (10) presence of female attire. Resnick summarize his “erotized repetitive hanging syndrome” as adolescent or young male who participate in a solitary masturbatory act using a binding apparatus that compresses the neck. 3
Supporting the Resnick features, Hazelwood et al 6 discusses 12 characteristics of autoerotic death to be taken into account at the scene:
1. Location : a secluded or isolated location such a locked room, attic, basement, garage, workshop, motel room, places of employment during non business hours, wooded areas, and summer residences. 2. Victim position : most commonly the victim´s body is partially supported by the ground such that she/he is suspended upright with only the feet touching the surface. 3. Injurious agent : most common was a ligature compressing the neck 4. Self rescue mechanism : any provision that the victim has made to reduce or remove the effects of the injurious agent such as a slip knot or knife for a ligature 5. Bondage : refers to the use of physically restraining materials or devices that have sexual significance for the user (this characteristic is often responsible for the misinterpretation of these deaths as homicidal versus accidental). 6. Sexual masochistic behavior : the deceased sometimes inflicts pain upon his/her genitals, nipples, or other body parts. 7. Attire: The victims are occasionally dressed in one or more articles of female clothing (the family often alters the scene due to shame, embarrassment or impulse). 8. Protective padding : the victim is found with soft material between the ligature and adjacent body part to prevent abrasions and bruising.
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9. Sexual paraphernalia : vibrators, dildos and fetish item such as female garments, leather, and rubber items are found on or near the victim. 10. Props : items such as mirrors, pornography magazines, pornography websites, photographs and films. 11. Masturbatory activity : the deceased may or may not engage in manual masturbation during the fatal autoerotic activity and the presence of seminal fluid has to be interpreted carefully. In some cases it is not a useful clue in determining whether death is due to autoerotic misadventure. 12. Evidence of previous experience : elicited from relatives and associates, permanently affixed protective padding, suspension-point abrasions, witnessed events, complexity of injurious agent and collected materials.
3.6 CARACTERISTICS OF ASPHYXIAL GAMES
Reference to choking games in the medical literature and in particular psychiatric literature is very limited. Only in the last decade, there has been a boom around the phenomenon possibly due to cases published on the Internet, the press and television. In fact before 2000 there is no reference to these deaths in the Medline database. The first scientific paper reviews of these practices in adolescents (D Le, AJ Macnab) 37 only appears until 2001 where there is a retrospective review of cases of self-strangulation with towel dispensers in Canadian schools.
The origin of the term "choking games" is not clear, but appears as a term in keywords in scientific articles. In this respect Katz and Toblin (2010) 38 has suggested using the term "strangulation activity" rather than the colloquial "choking games" pointing out the etiological type and wishing to reflect the potential risk to life inherent to this behavior. The more correct term is probably unintentional death by asphyxiation as it allows to not only include deaths by strangulation, but by other types of asphyxia. Only in the last decade asphyxia games have been referenced in publications on pediatrics,
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emergency medicine and public health.
Very recently French author Michel Gregory (2006) 39 at the Psychopathology of Childhood and Adolescence Service at Robert Debré Hospital, in Paris, described the violent games played by children and adolescents and classified them into aggression and oxygenation games. The first set corresponds to heteroagression games where physical violence is used, usually by group of young people against a victim (bullying). The second group is the objective of this review and includes all games involving asphyxiation type of maneuvers with subsequent strangulation and suffocation which result in cerebral hypoxia, i.e. unintentional suffocation (most of them self-inflicted).
The author describes what has been termed "initiation or experimentation phase" which usually occurs in groups within the recreation area or the bathrooms of schools in the absence of adults. There is no defined role for the victim who later becomes the aggressor making the practice often consensual and reciprocal: the choked becomes strangler and vice versa. Many young people often agree to participate in the game, often under pressure from peers. The most common practice known as "jeu du foulard", literally "the scarf game" (curiously scarves are rarely used) is to provoke an initial hyperventilation through repeated bending of the knees followed by strong inspirations (hypocapnia). Then one of the participants compresses the carotid neck to trigger the effect of cerebral hypoxia (strangulation). The hallucinatory sensations are: being lifted off the ground, depersonalization, seeing brightly colored circles, etc. The game is repeated many times by increasing the time of compression. There are some variations of the game involving compression of the sternum or the rib cage (Valsalva maneuver) as in "tomato stake" or "frog game".
Linkletter et al (2010) 40 conducted an interesting study based in assessment of asphyxial games videos available in the web site YouTube. For searching purposes they used the “street names” of asphyxia games most commonly utilized by students: “Choking game”, “Space Monkey”, “Flatliner”, “Space Cowboy”, “Suffocation roulette”, “Sleeper hold”, “Rising Sun”, etc. They identified a total of 65 videos between October 22 and
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November 2, 2007 from postings to YouTube. The technique used varied substantially: The most common practice involved the individual squatting or bending, followed by standing quickly. Then a partner (the chocker) applied pressure to the chest until loss of consciousness. At least 27 videos (42%) were related with this practice.
The second most common practice was “sleeper hold”. In this practice, the choker applied pressure to the neck of the subject wrapping an arm or a forearm around and compressing the neck by standing behind. This practice was documented in 24 cases (37%). The next most common practice: involved a compression on the chest or neck of a standing subject, was used in 8 cases (12%). In two cases there was a variant of this technique in which the subject added hyperventilation. The last method described with 4 cases (6%) involved only an individual who squatted and hyperventilated then stood rapidly and perform a Valsalva maneuver or breathe holding.
Seizures due to hypoxia (55%) were documented in 36 videos and 25 (38%) showed no signs of convulsion; in the remaining 4 videos it was impossible to establish with certainty the possibility of seizure due to an observer blocking the camera. Seizures were more frequent in those videos that used the technique of "sleeper holder" compared to the other methods (P <.001). In these cases the seizures were documented in 21 of the 24 cases (88%). Seizures occurred in 3 of the 4 videos among those who curled up and then stood up, hyperventilated and then applied Valsalva or held their breath,. The seizures were less frequent in cases of snuggling or bending followed by standing and then in the chest or neck. Within this group, seizures occurred in 11 of 27 cases (41%). When pressure was applied to the neck or chest while the person stood without curling previously, only in 1 of 8 cases showed seizure. Both the older participants and younger had the same risk of seizures. The complete results are shown in Table 2.
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Table 2. Outcome With Various Techniques of Asphyxial Games. From: Linkletter M, Gordon K, Dooley J. The “choking game” and YouTube: a dangerous combination. Clin Pediatr .2010; 49(3):274-279. Age (Years) Techniques Used Frecuency 12 - > Percentage Percentage Porcentage (%) 18 18 With Without Unclear if Seizure Seizure Seizure Squat/bend at waist, 42 13 14 41 48 11 hyperventilate, stand quickly; choker applies pressure on neck/chest Sleeper hold 37 11 13 88 8 4 Stand,± 15 8 2 10 90 0 hyperventilate; choker applies pressure on neck/chest Squat, hyperventilate, 6 3 1 75 25 0 stand quickly, Valsalva maneuver/hold breath
3.7 AIMS
If the number of adults who practice autoerotic asphyxia is unknown, much more so is the number of preteens and teenagers involved in asphyxial games. Only in the last decade the issue gained widespread communication through the media in a kind of “boom”, especially in newspapers and television programs. Unfortunately the approach taken by the media is too sensationalist and distorts the understanding of the syndrome by the society, educators, families and even the medical community itself.
Some authors believe that autoerotic asphyxia in adolescents is an entity distinct from asphyxia games because of the sexual component found in the former, which is accompanied by masturbation and paraphilia such as sadism-masochism and the restriction. However other authors consider that there is a close link between both practices and that the games are nothing more than the early stage in the development of one or more paraphilia in adolescence and adulthood.
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The purpose of this study is
• Outline any issues relevant to asphyxial games in adolescence and describe
their characteristics, the profile of its practitioners and potential risk factors.
• Examine comprehensive literature of all fatal cases involving unintentional
asphyxia in adolescents (autoerotic deaths asphyxiation and asphyxia
games) reported in medical journals and publications to determine the
characteristics of these practices in this population in particular, and to find
possible commonalities or differences between them.
• Review literature in psychology and psychoanalysis to understand the
etiology of asphyxial behavior and its implications.
• Make a critical analysis of literature in forensic pathology, psychology,
psychoanalysis and discuss whether both behaviors (adolescent autoerotic
asphyxiation and choking games) might correspond to a single syndrome or
may be considered as separate entities.
• Increase awareness about unintentional asphyxia for health professionals,
forensic pathologist and educational establishments in order to gain a better
understanding of the situation.
• Cite some recommendations for further studies in the area and the
development of measures to prevent these deaths.
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4. RESULTS
4.1 WHO PLAYS ASPHYXIAL GAMES
Macnab et al. (2009) 41 conducted a study based on surveys taken among 2504 students in grades 4 to 12 with ages between 9 and 18, from 8 schools and of higher education in Texas (USA) and 2 in Ontario (Canada). The average age of respondents was 13.7 years (SD: 2.2), median age 13. In this study 68% of young people had heard about the game and 58% of these were men. A total of 45% knew someone who practiced the game and 6.6% admitted had participated in such games. Of these 93.9% practiced it with someone else. 40% of respondents did not perceive any risks with the playing of games. Of 6.6% who admitted having carried out the practice, 55% were men. Of those who had carried out the practice 94% did so with someone else being present.
An interesting result is that all girls who have played the game accepted having had company. Ten young men (11%) did so alone. 58% of respondents who said they practiced choking game reported continuing to do so. The percentage of children who continued to participate in these games varied according to age. The highest percentage (6-10%) was within the range of 15 to 17 years. The researcher was struck by the discovery that even though one of the schools surveyed had recently suffered the death of a student by asphyxiation games and five of the schools were located in a state where two victims were reported, 95 of the respondents agreed to continuing to play the game and more than a third knew the game before publications informing of deaths by the press and television.
In the U.S., Ramowski et al. (2010) 42 and Public Health Division of Oregon surveyed the school population of 8 schools. In 2008, all 647 schools and higher education were taken into account in the study. A sample of 114 schools with a total
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of 10,642 participants was selected. The objective was to assess the familiarity and participation in this activity. The results indicated that 36.2% of 8th grade students had heard of the choking game, 30.4% had heard of someone close who participated and 5.7% acknowledged having participated. Young people in rural areas were significantly more likely to practice than those in urban areas. The practice of games of suffocation was higher in those at high risk of developing mental illness and in adolescents who had a history of substance abuse.
Dake et al. (2010) 43 conducted a study in Ohio between autumn 2008 and autumn 2009. They did a total of 3408 surveys in 192 classrooms in 88 state schools. They established two categories of schools: middle school and high school. The prevalence of activity in high school students was double that of middle school (11% vs. 5%) which shows the practice increasing with age. As for the sex distribution the study shows a higher prevalence for males in both middle school students as well as in high schools. The investigation showed a participation rate of 9%.
The evaluation of the prevalence of choking games in middle school ages (12-15 years) indicate that these were significantly more likely to be found in students with the following characteristics: age (25% for 15 years age), live in single-parent families (9%) and receive low grades (Ds and Fs) (17%). Additionally, the asphyxial games were significantly higher in students who reported the following risks: exposure to physical violence (15% -22%), mental health issues (12-30%) and substance use (21% -37%).
Because previous research had shown that selected demographic characteristics (e.g. gender and age) affect the prevalence of participation in asphyxia games, the researchers decided to monitor the effects of demographic variables and risk factor adjusted to odds ratios (AOR) and confidence intervals of 95%. The variables most significantly associated with participation in games of suffocation for middle school students were: being over (15 years old) (AOR = 25.3),
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marijuana use in the last 30 days (AOR = 19.9), cigarette smoking in the last 30 days (AOR = 14.9) and consumption of alcohol in the last 30 days (AOR = 12.2).
High School students (14-18 years) involved in choking games share several common features with those in middle school. These participants were more likely to be male (14%), with families with a stepparent (17%) and students with low grades (Ds and Fs) (27%). In relation to association behavior, the following were associated with high prevalence of behavioral “choking game”: having more than 4 sexual partners (22%), exposure to physical violence (22% -33%), mental health issues (16% -30%) and substance use (18% -29%).
An analysis of the adjusted odds ratios (AOR) for demographic variables showed a total of 23 variables significantly related to high school students involved in asphyxial games. The variables most closely related to choking games were: age (compared with middle school students) (AOR :7.0-9 .6), being forced to have sex (AOR = 4.5), inhalant use (AOR = 3.4) , mental health issues (AOR = 3.2) and excessive alcohol consumption in the last 30 days (AOR = 3.0).
The study is complete (it should be noted that Dake took a broader age range than that used by Ramowski and Macnab) and reduces the risk of bias by controlling the five demographic variables with adjusted odds ratios and confidence intervals of 95%. Whether the practitioner of the games was alone or accompanied at the time of practice was not taken into account in this study and is one of its limitations.
Le Heuzey (2011) 44 cites a survey conducted in the school population in France between 746 students, of whom 70% had knowledge of the game, 10% had practiced it and 3% habitually practiced it (all male). The year that the survey was conducted is not mentioned. The games were practiced by children from 5 to 17 years with a mean of 12 years.
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Ramowski et al. (2012) 45 discussed a further follow-up survey conducted in Oregon in 2008. He sampled 5348 schoolchildren aged 12 to 15 years. In this review, 22% of 8th grade students reported that they had heard information about the games, 1.2% admitted to having helped someone during the game and a 6.1% accepted having played the game alone. The study found no significant differences regarding sex nor concerning rural compared to urban population. Youth with better academic performance were less likely to participate than those with lower grades. The most important advance in this study was to assess bivariate regression models between health risk factors for and the playing of games of suffocation. The results showed that the latter are significantly associated with six risk factors: mental health disorders, substance abuse, exposure to violence, sexual activity, malnutrition and gambling.
When doing a multivariate analysis no differences were found in predictive risk factors between men and women. Sexual activity and substance use was common in both sexes. But for women the strongest predictor was the sex: young women who were sexually active were given 4 times more to playing the games of suffocation than those without sexual initiation. (OR: 3.97 [95% CI :2.4-66]). Other predictors were substance abuse (OR: 2.11 [95% CI :1.4-3 0.3]) and gambling (OR: 1.72 [95% CI :1.3-23]). In the case of men substance abuse was the strongest predictor of choking game (OR: 3.87 [95% CI :1.9-7 .7]), followed by sexual activity (OR: 3.01 [95% CI: 1.5-3.1]). Although some young people admitted to the carrying out the practice only once, most participants (64%) had done it at least twice and a fifth of them more than 5 times. The above result shows a clear tendency to repetition in the practitioners. Recalling what Macnab documented regarding the association between gender and repeated practice alone, a tendency to repetition while being alone was more predominant in males. The study only took into account 8th grade students between 12 and 15, which is not very large range.
Lastly, it is worth the study conducted by Linkletter et al (2010) 39 is quoting again. As mentioned above, videos about practitioners of asphyxiation games on the
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website YouTube were evaluated. With a total sample of 65 different videos there were 10 cases (15%) where only the practitioner and a companion were present. In the remaining 55 observers were shown watching the game. A total of 110 participants / observers were identified in the 65 videos to be mostly men (n = 99, 90%). The estimated age of the participants was 12 to 18 years in 35 of 65 videos (64%) and over 18 years in the remaining 30 (46%). The activity usually took place in a private quarter.
Linkeletter, also measured the "popularity" of the videos and found that a total of 65 videos in the study were seen 137,550 times. The average video was viewed by 2,670. Three weeks after the collection of data the percentage of visitors had increased by 61%, at this point the number of viewers had increased to 279,240 with an average of 4296 views per video. One video in particular that shows the practice of the game by several young men in a dormitory and in which two participants have seizures was viewed 27,507 times. The 65 videos were marked as "favorites" a total of 721 times with an average of 11 times per video.
Participation rate in all series are shown in table 3.
Table 3. Participation rate of students in asphyxial games
Study Participation rate %
Macnab et al (2009) 6.6
Dake et al (2010) 9
Le Heuzey (2011) 10
Ramowski (2012) 6.1
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Summary key characteristics of living participants of asphyxial games and risk factors related are shown in tables 4 and 5.
Table 4. Key characteristics of asphyxial games living participants
• Frequency tend to increase with age • Game is played mostly in group • Repetition associated with solitary practice • No significant gender differences in survey participants. However, females tend to play in group. Repetition and solitary practice is linked to male • In video records evidence, mostly of participants are male. • Not perceived as a life-risk behavior
Table 5 . Risk factors linked to living players of asphyxial games
Dake et al (2010) Ramowski et al. (2012)
Being older >15 years Poor nutrition
Exposure to physical violence Exposure to physical violence
Substance abuse Substance abuse
Sexual activity Sexual Activity
Non 2 parent family Gambling
Low academic performance Low academic performance
Mental health issues Mental health issues
4.2 WHO ARE THE VICTIMS OF AUTOEROTIC ASPHYXIA IN GENERAL POPULATION
Using the tools described in the section on methods there are multiple allusions to series of cases related to autoerotic asphyxiation and unintentional deaths by asphyxiation. As explained above, the study focuses on the study of all types of unintentional asphyxia in preadolescent and adolescent populations.
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It is noteworthy that during the research three extensive reviews of the general literature on autoerotic deaths were found. Two of them Uva (1994) 15 and Shields (2005) 46 focus on autoerotic asphyxiation and one of them Sauvageau (2006) 2 on autoerotic deaths, including deaths different from asphyxia. These reviews included studies of series and reports of fatal cases cited in the present study. However, they did not focus on the adolescent population. In reviewing these articles no connection with asphyxia games was found nor mentioned. The articles were taken into account to facilitate the search for series of cases of autoerotic asphyxiation, which included adolescent population, and to review concepts, general literature and corroborate results.
The aim is to identify whether there were teenagers among deaths classified as autoerotic asphyxiation as well as age groups found in each of the studies, their frequency and to evaluate the variables of sex, kind suffocation involved and the place where asphyxiation is practiced. A total of 10 studies of series of cases that involved autoerotic asphyxiation in the general population were found. The results are shown in Table 6.
The studies are quite comprehensive and include several countries: USA, Germany, Denmark, Canada and Australia. The oldest corresponds to Walsh 47 published in 1977 and the most recent Byard 48 (Australia), published in 2012. Some include long periods of evaluation as presented by Behrendt 49 in Denmark who studied a 57-year period between 1933 and 1990. The study with the highest number of cases was conducted by Blanchard and Hucker 50 in Canada between 1974 - 1987 for a total of 117 cases.
4.2.1 Gender
All studies show an almost absolute prevalence of males. In fact, with the exception of studies by Hazelwood (1983) 6 and Byard (2012) 48 who report a few cases of women, all reported victims are male. In Hazelwood the percentage of women is only 5.7% and in Byard only 4.5%.
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Table 6. Series of fatal cases of autoerotic asphyxia in general population. Andrés Rodríguez Zorro
Reference Year Country Period Number Sex Age Mean Type of asphyxia I/O Emplacement of cases Age
Walsh et al 47 1977 USA 1958- 43 M 14-75 <30: 77% All forty three neck ligature compression 43 ND 43ND 1973 Hazelwood et al 6 1983 USA 1970- 70 66M 9-77 26.5 Forty-four hanging; six neck compression; 12 airway 70ND 70ND 1978 - 4F obstruction, four chest compression; two oxygen exclusion with gas or chemical replacement Diamond 52 1990 USA ND 8 M 15-59 ND Six hanging; one plastic bag; one smothering (pillow) 7I One public location; ND for the rest
Blanchard and 1991 Canada 1974- 117 M 16-76 26 Ninety-three hanging; seven plastic bag + gas or 117 117 ND Hucker 50 1987 solvent; six ligature strangulation; five plastic bag; ND three hanging + plastic bag; one chest compression; one gas or volatile solvent: one ligature strangulation + plastic bag Tough et al 53 1994 Canada 1978- 19 M 15-50 28 Eighteen hanging, one inhalation of solvent 19I 19 ND 1989 Behrendt and 1995 Denmark 1933- 46 M 10-71 31 Twenty hanging; 14 plastic bags, six gas or substance 80%I 58% bedroom or living room, Modvig 49 1990 inhalants, two strangulation, two positional asphyxia, 14% bathroom, 8% adjacent two non asphyxia deaths room
Bretmeier et al 51 2003 Germany 1978- 17 M 16-76 36.8 Seven asphyxia by strangulation; four suffocation, one 14I Eleven apartment, one car, one (Hannover) 1997 asphyxia by drowning, four non asphyxia deaths jail cell, one hotel room
Shields et al 46 2005 USA 1993- 16 M 14-59 38.3 Twelve hanging, four ligature strangulation 15I Five bedroom, four basement, 2001 two home, two cabin, one garage, one front hall
Janssen 54 2005 Germany 1983- 40 M 13-79 <39: 50% Seventeen hanging; three ligature strangulation; 37I Indoor: Bedrooms, bath, cellar, (Hamburg) 2003 suffocation in eleven cases; two thoracic compression; hotel room. Outdoor: Cabin of One positional asphyxia; Six non clear differentiated. sex cinema, bridge, rubbish container. Byard 48 2012 Australia 2001- 44 42M- 10-69 <39:52% Hanging in forty cases; four non asphyxia deaths 44ND 44ND 2007 2F
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4.2.2 Age
All groups show victims in the age of adolescence. Hazelwood's study (1983)6 shows victims as young as nine; Behrendt and Modvig (1995) 49 and Byard (2012) 48 from ten year-olds. Blanchard and Hucker (1991) 50 and Bretmeier et al. (2003) 51 report ages of initiation at 16.
The results show that in all studies the age range is quite wide and extends from the preteen / teens to adult group. However when analyzing the average age it is surprising that the vast majorities are in the group of adolescents and young adults. In fact in all studies provided that more than 50% of victims were under age 40. Blanchard and Hucker (1991) 50 and Hazelwood (1983)6 show median ages of 26 and 26.5 years respectively. Walsh (1977) 47 shows that 77% of victims were under 30 years.
4.2.3 Type of asphyxia
Studies show a marked prevalence of asphyxia by neck compression and within these mainly hanging; ligature strangulation and suffocation followed. In some cases such as the study by Walsh (1977) 47, 100% was due to neck compression. In Hazelwood (1983) 6, 62% were by hanging, 8.5% by strangulation (a 70.5% consolidated to asphyxiation by neck compression). Blanchard and Hucker (1991) 50 group the greatest number of cases by hanging at 79%.
4.2.4 Place of occurrence
While some of the series of cases analyzed do not take this detail into account, those that do clearly show a predominance of closed scenarios within the home (indoors). Diamond (1990) 52, Tough (1994) 53, Bretmeier et al (2003) 51, Shields et al (2005) 46 and Janssen (2005) 54 show that over 80% of cases occur in such places. In the study by Behrendt and Modvig (1995) 49 the prevalence of closed spaces is 80%. The most common scenarios are bedrooms followed by bathrooms, basements and garages.
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Summary of key characteristics of victims of autoerotic asphyxial in general population are shown in table 7.
Table 7. Key characteristics of victims of autoerotic asphyxia in general population
Age In all series there are adolescents reported. Mostly of victims are compressed in adolescence and young adults.
Gender Mostly of victims are male
Type of asphyxia Marked prevalence of neck compression asphyxias, mainly hanging.
Emplacement Predominant indoors scenes
Context Solitary, secrecy, clandestine activity.
4.3 WHO ARE THE VICTIMS OF AUTOEROTIC ASPHYXIATION IN ADOLESCENCE
Reports of 15 cases of deaths of adolescents from 1988 to 2005 were found in Canada, USA, United Kingdom, Bulgaria, Denmark and Germany. (Shown in Table 8). The first case was reported by Byard and Braumwell (1988) 55 in Canada, an unusual case of a female involved with transvestite fetishism. Sheehan et al (1995) 56 makes a detailed review of nine cases occurred between 1975 and 1985 in the state of Minnesota. Two reported cases were not considered for this study. The first did not have clear autoerotic features (only describes the shaving of pubic hair as a sign of sexual activity). The second was excluded because it involved a 20 year old (the study includes only cases up to 19 years of age according to the definition of adolescence and the World Health Organization).
Kirksey et al (1995) 57 published two fatal cases of boys who arrived in full cardiopulmonary arrest to Emergency Department of University Hospital in San Antonio (Texas). Henry (1996) 58 describes a death of 12 years old boy in the midlands UK in 1977 firstly taken as suicide with transvestite fetishism component. The scene was modified: the mother and aunt decided to redress the boy in his underpants, his normal
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night wear, before summoning help. Shields et al. (2005) 46 reported a total of 11 cases of which two are adolescents. One case is dismissed because it corresponds to an autoerotic death involving electricity but no asphyxia maneuvers. Findings like bondage and transvestite fetishism were described. Single cases were reported by Doychinov et al (2001) 59, Behrendt et al (2002) 60 y Koops et al (2004) 61. Listed below is the analysis of sex, age, and type of asphyxia, place of occurrence and add the variable type of paraphilia associated with the practice of asphyxiation.
4.3.1 Gender
There is absolute predominance of male patients with a total of 13 victims (86.6%) and only two females (13.3%). (6.5:1 male: female ratio).
4.3.2 Age
Ages range from 12 to 19 years. Mean age is 15.4 years and the median 16 years. It should be remembered that within the series of autoerotic asphyxiation cases there are reported cases since age 9. The age analysis of the most relevant information points to a direct correlation across age variables associated with type of paraphilia. In this review paraphilias are describe as early as 12 years. Henry (1996) 58 described a case of a young boy of 12 years with fetishism / transvestitism. Sheehan et al (1988) 56 also show a case of fetishism / transvestitism in a 13 years old boy. As age increases transvestite fetishism seems to appear, a finding consistent with the study of Blanchard et al (1991) 49 who showed in a series of 119 cases that the proportion of bondage and fetish / transvestitism increased with age.
4.3.3 Type of asphyxia
Asphyxia by neck compression was the method most commonly appearing in 12 cases (80%). Of these 10 (66.6%) correspond to hanging and 2 ligature strangulation (13.3%). In the remaining three cases (20%) the asphyxia type corresponds to suffocation.
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Reference Year Country Sex Age Method Type of asphyxia I/O Emplacement Type paraphilia
Byard and 1988 Canada F 19 Ligature neck compression Ligature Strangulation I Bedroom Transvestite Fetishism Bramwell 55
Sheehan et al 56 1988 USA M 13 Ligature neck compression Hanging I Home Bondage
Sheehan et al 56 1988 USA M 14 Ligature neck compression Hanging I Bedroom Voyeurism (mirror)
Sheehan et al 56 1988 USA M 14 Plastic bag - Propane inhalation Suffocation I Garage
Sheehan et al 56 1988 USA M 14 Ligature neck compression Hanging I Basement Transvestite Fetishism
Sheehan et al 56 1988 USA M 16 Ligature neck compression Hanging I Basement
Sheehan et al 56 1988 USA M 16 Ligature neck compression Hanging I Bathroom Voyeurism (mirror)
Sheehan et al 56 1988 USA M 16 Ligature neck compression Hanging I Home Transvestite Fetishism
Kirksey et al 57 1995 USA M 13 Ligature neck compression Hanging I Bedroom Bondage
Kirksey et al 57 1995 USA M 17 Ligature neck compression Hanging I Home Transvestite Fetishism
Henry 58 1996 UK M 12 Ligature neck compression Hanging I Home Transvestite Fetishism
Doychinov et al 59 2001 Bulgaria M 18 Ligature neck compression Hanging I Bedroom Transvestite Fetishism
Behrendt et al 60 2002 Denmark F 17 Plastic bag Suffocation I Bedroom Bondage
Koops et al 61 2004 Germany M 16 Ligature neck compression Ligature Strangulation I Bedroom Transvestite Fetishism
Shields et al 46 2005 USA M 17 Gas (butane) inhalation Suffocation I Home
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4.3.4 Place of occurrence
All cases (100%) occurred in indoors scenarios like homes, mainly in bedrooms (42.8%). Other places described were bathrooms, garages and basements. In all cases deaths occurs in a context of solitary activity.
4.3.5 Type of paraphilia
Interestingly, it was found that documented paraphilia occurred in early adolescence. In 12 cases (80%) at least one of these types were established. The most common paraphilia is fetishism / transvestitism where there were a total of 7 cases (46.6%) reported; bondage with 3 cases (20%) and voyeurism with two cases (13.3%) followed. In three cases (20%) did not report any paraphilia, however pornography, nudity and / or masturbation were evident. As mentioned in the age analysis, there seems to be a direct correlation between increasing age and the type of paraphilia involved.
Summary of key characteristics of victims of autoerotic asphyxia in adolescents are shown in table 9.
Table 9. Key characteristics of victims of autoerotic asphyxia in adolescents
Age Deaths are documented in both: early and late adolescence
Gender Almost all victims are male
Type of Marked prevalence of neck compression asphyxias, mainly hanging. asphyxia
Emplacement Predominant indoors scenes
Context Solitary, secrecy, clandestine activity.
Paraphilias Paraphilias are common in adolescence and tend to increase with age
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4.4 WHO ARE THE VICTIMS OF ASPHYXIAL GAMES
For author Michel 39 the magnitude of this phenomenon is very difficult to assess because it is a type of game played outside adult control. The consequence of this practice is often interpreted in terms of accidents, but still many are wrongly classified as suicides. The numbers are contrasting and controversial. In France parent associations speak about figures ranging from 90 to 200 fatal cases. On the other hand the Croissandeau report conducted in 2002 by the General Inspectorate of Education in this country found only a dozen cases since 1990. 62
According to the report the victims were aged between 11 and 15 years; most of them in elementary school and a few in high school. High school students involved had initiated the practice in elementary grades. All fatal cases reported were male. All the victims apparently engaged in group play during middle school or holiday activities. However, the author notes that in his clinical experience they have identified that the practice of these games alone in the home and are an indicator of a severity and seriousness to which we must pay close attention. According to the study most of the deaths occur precisely at home.
The Croissandeau study posits three different types of practitioners:
1. Occasional : those motivated by curiosity or are driven by peer pressure.
2. The regulars : Very given to experiment and search for new sensations. They are repeating the game and practice it at home alone.
3. Suicides : Subjects with fragile personality. The most unusual group yet at high risk of accident and death.
In the present study, the number of articles reporting cases of choking games is quite small. Only five references that meet the inclusion criteria proposed in this study are shown. A total of 12 fatalities were reported. See Table 10.
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The first of these references is by the Canadian Authors D Le and Macnab (2001) 37 who describe hangings of children and adolescents related to towel dispensers, within their schools. Both used the Med LARS method and reviewed cases published in the newspaper and checked reports of Medical Examiners in the period between 1966 and 2000. Of a total of five cases reported, one survived. The remaining four are included in this study.
The second reference Burch et al. (1995) 63 is a very peculiar case that occurred in St. Charles County, Missouri (USA) in which the victims, two children under 7 and 8 years respectively, placed a shoelace around the neck and consented to be sodomized by two other minors of 10 and 13 years respectively. The case was included in the study because victims themselves voluntarily placed the ligature around the neck. The case is interesting because it shows a clear association between asphyxial games and a sexual component at an early age.
Andrew (2007) 64 describes three cases in the state of New Hampshire (USA) in which three males of school age, 9, 13 and 11 respectively, appeared hanging inside their rooms. The first had been seen by his sister several times playing with a string around the neck in his room. In the second case the child's mother brought to the medical examiner's office emails that involved the child in the practice of game known as "space monkey". In the latter case, which occurred just six weeks after the second, the child had knowledge of the game. The author mentions two other highly suspicious cases involving school children age 12. Both of these were classified by the office of medical examiner as suicide in one case and as undetermined in the other. For this reason they were not included in his review.
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Table 10. Fatal cases of asphyxial games reported in literature.
Reference Year Country Sex Age Method Type of I/O Emplacement asphyxia
Burch et al 63 1995 USA M 7 Ligature neck Ligature O Wood compression Strangulation
Burch et al 63 1995 USA M 8 Ligature neck Ligature O Wood compression Strangulation
D Le- Macnab 37 2001 Canada M 11 Ligature neck Hanging I School - compression Bathroom
D Le- Macnab 37 2001 Canada M 7 Ligature neck Hanging I School - compression Bathroom
D Le- Macnab 37 2001 Canada M 7 Ligature neck Hanging I School – compression Bathroom
D Le- Macnab 37 2001 Canada M 9 Ligature neck Hanging I School – compression Bathroom
D Le- Macnab 37 2001 Canada M 12 Ligature neck Hanging I School – compression Bathroom
Andrew 64 2007 USA M 9 Ligature neck Hanging I Bedroom compression
Andrew 64 2007 USA M 13 Ligature neck Hanging I Basement compression
Andrew 64 2007 USA M 11 Ligature neck Hanging I Bedroom compression
Egge 65 2010 USA F 12 Ligature neck Hanging I Bedroom compression
Barbería- 2010 Spain M 15 Ligature neck Hanging I Bedroom Marcalain 66 compression
Egge (2010) 65 published the only article that documents a female victim, which occurred in Los Angeles (California). It also corresponded to hanging inside her bedroom. The victim was resuscitated and transferred to an intensive care unit where brain death evolved. In this case one of her cousins and classmate testified to having played with her at compressing the neck with garments in the past.
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In the last of these cases Barberia-Marcalain et al. 66 describe a case in the Autonomous Community of Catalonia involving a 15 year old found inside his room on one knee with his elbows on a cushion and neck placed inside a loop in a "U" shape which was attached to the top of the bunk bed. At the time of death the teenager was playing with the loop to gradually compress the neck while playing video games with a handheld console.
The investigation found another reference in Spanish by Baquero et al. (2011) 67 who mentions the occurrence of 8 cases of choking game deaths between August 2009 and 2010 in the province of Rosario in Argentina. Because a description of the cases and the characteristics of the scene are not described, the story was not considered for this study. However, it does provide relevant information regarding a trend of occurrences of multiple cases in a short period of time, which may have been influenced by the media and the Internet.
The largest study in this review of cases related to fatal “choking games” was conducted by Toblin et al, 8 members of the division for the Prevention of Unintentional Injury Prevention at Center for Disease Control in Atlanta (United States) in 2008. The authors analyzed the deaths of young people between 6 and 19 years of age, between 1995 and 2007, using as source the LexisNexis® method based on reports of articles published in newspapers across the United States. They initially found a total of 106 deaths related to suffocation games of which 20 items were ruled out due to suspected suicide as provided by the medical examiner's office; one because the age of the victim was not clear and 3 due to having autoerotic elements (to my mind a bias in the research).
They documented a total of 82 deaths related to choking games. The earliest documented cases date from 1995. Three or fewer deaths occurred in the period between 1995 and 2004, but 22 deaths occurred in 2005, 35 in 2006 and 9 in 2007. Seventy-one (86.6%) of the 82 dead were male. The reported age range was 6 to 19 years with a mean age of 13.3 years (standard deviation: 2.1) and a median of 13. The age distribution of deaths related to asphyxia games during the period 1995-2007 differs substantially from 5.101 young people aged 6-19 years whose deaths were attributed to suicide hanging /
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suffocation during the same period. The finding confirms that they are completely different phenomena.
In 70 deaths where information provided was sufficient, 67 cases (95.7%) occurred when the victim was alone. In 42 cases with complete information, 39 (92.9%) parents of the victims said they were not aware of the practice until their children had died.
4.4.1 Gender
Of the 12 documented cases, 11 (91.6%) were male, a finding similar to the series of cases studied by the CDC in Atlanta (86.6%). Only Egge's article (2010) 64 describes the case of one female victim.
4.4.2 Age
Cases from 7 to 15 years with an average of 10.8 years were described with standard deviation of 2.4 and a median of 10 years. The epidemiological study of the CDC reported the age range was 6 to 19 years with a mean age of 13.3 years (standard deviation: 2.1) and a median of 13. The data are consistent in both sets of cases.
4.4.3 Type of asphyxia
All articles show related cases of choking by compression of the neck (100%). Ten of them (83%) are by hanging, and two of them (16.6%) with ligature strangulation. The study of the CDC in Atlanta does not discriminate the type of asphyxia. However it is clear that most choking games published in the media in U.S. territory correspond to neck compression maneuvers since the study defined cause of death as auto strangulation.
4.4.4 Place of occurrence
Indoors were the most prevalent. Ten of the scenes (83%) occurred in youngsters home, more precisely in their rooms. Only two cases (16.6%) occurred in open scenes
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(two cases already mentioned that occurred in a forest). However 100% of the cases took place secretly, while children were alone; in a similar finding to that reported by the CDC in Atlanta shows that in 95.7% of cases the victims were alone at the time of play. A striking finding is that in the most recent cases, Andrew (2007) 64, Egge (2010) 65 and Barbería-Marcalain (2010) 66, siblings and playmates reported that there was prior knowledge of choking games. In a case reported by Andrew (2007) 64 tightening the neck with ropes were of long standing behavior.
Summary of key characteristics of victims of asphyxia games in adolescence are shown in table 11.
Table 11. Key characteristics of victims of asphyxial games
Age Deaths are documented in both: early and late adolescence
Gender Almost all victims are male
Type of All cases are related with neck compression asphyxias, mainly hanging. asphyxia
Emplacement Predominant indoors scenes
Context Solitary, secrecy, clandestine activity. Previous knowledge of the game.
4.5 COMPARATIVE ANALYSIS OF FATAL CASES OF ASPHYXIAL GAMES AND AUTOEROTIC ASPHYXIA
To identify common elements in each of the variables a comparative analysis follows of those variables taken from articles describing cases of fatal choking games among teenagers, a series of cases analysis of fatal choking games conducted by the Center for Disease Control and Prevention CDC in Atlanta, articles found relating to fatal cases of autoerotic asphyxiation in adolescents and the series of cases of auto erotic suffocation in general (adult and teenagers).
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4.5.1 Gender
In analyzing the gender variable all studies show a marked predominance of males versus females. All groups document prevalence above 86% for males. The prevalence of males is also very marked in autoerotic asphyxiation in adults.
4.5.2 Age
The three groups show fatal cases at an early age in childhood and preadolescence. Autoerotic deaths are reported cases of victims as young as 9 years. The CDC group samples cases occurring from age 6 and cases of fatal choking games there is one reporting a victim of age 7. All studies situate the maximum age in adolescence, after puberty, and are consistent. The results show that the deaths of the first three groups range from childhood / preadolescence and extend through adolescence. Recall that in adults the deaths occur in young adults (mostly between 3rd and 4th decade of life).
4.5.3 Type of asphyxia
In all groups asphyxia by neck compression dominate: 80% in autoerotic asphyxiation adolescent (the same pattern is observed in auto erotic asphyxiation in adults). In asphyxial games all fatalities (100%) are reported to be by compression of the neck. In adults the majority of victims asphyxia corresponds to compression of the neck. The most common type of asphyxia in all groups was hanging.
4.5.4 Place of occurrence and status of the victim
The articles relating to deaths by autoerotic asphyxiation in both adults and teenagers always discard the presence of a second person when assessing the manner of death consequently the victim must have been alone in all cases. The scenes are mostly indoors and occur within the home. In the case of the choking game, 10 of the 12 cases the children were alone at home. In the 2 remaining cases of fatal choking games, the victims were not alone (there was consensual sexual activity with two children) and the act was carried out in a forest, however the practice was performed in a clandestine
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manner. In CDC group 95.7% of the deaths occurred while the victim was alone.
A profile comparison between fatal cases of autoerotic asphyxia and asphyxia games are shown in table 12.
Table 12. Profile comparison between fatal cases of autoerotic asphyxia and asphyxial games
Autoerotic asphyxia Autoerotic asphyxia Asphyxial games (General) (adolescents)
Age In all series are Deaths are documented Deaths are documented adolescents reported. in both: in both: Mostly of victims are early and late early and late compressed in adolescence adolescence adolescence and young adults.
Gender Mostly of victims are Almost all victims are Almost all victims are male male male
Type of Marked prevalence of Marked prevalence of All cases are related asphyxia neck compression neck compression with neck compression asphyxias, mainly asphyxias, mainly asphyxias, mainly hanging. hanging. hanging.
Emplacement Predominant indoors Predominant indoors Predominant indoors scenes scenes scenes
Context Solitary, secrecy, Solitary, secrecy, Solitary, secrecy, clandestine activity. clandestine activity. clandestine activity. Release mechanism Release mechanism Previous knowledge of games.
Paraphilias Very common Present from early N.A ? adolescence
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5.0 DISCUSSION
5.1 ETIOLOGIC THEORIES
Traditional conceptualization of autoerotic asphyxiation and other paraphilia is based on psychoanalytic concepts relating to Freud’s theory of psychosexual development. As mentioned previously, Resnik (1972)3 described the autoerotic asphyxiation as "eroticized repetitive hangings." He stresses that the intention is not to produce death and that there are attempts to hide the marks or grooves of the neck pressure. The author reviewed clinical reports and found other commonalities that he describes as "upward displacement of castration anxiety" (e.g. the penis into the neck). In this scheme the penis is represented by the neck, which is symbolically "castrated". Ejaculation then calms anxiety, which symbolizes having survived castration.
Resnik explains sexual asphyxiation as a result of castration anxiety; possibly arising from conflicts early in the oral psychosexual development produced by a mother breastfeeding her child so enthusiastically that partial asphyxiation or suffocation is associated with the pleasure of being nurtured. The newborn may experience asphyxiation by the act of the mother compressing its face to her breast before receiving milk, or when the baby holds its breath while crying before being properly nursed. The author believes that these many be early determining factors to searching for similar sensations in later stages of life (e.g. pleasurable experiences induced by hypoxia, anoxia, hypercapnia by neck compression, partial suffocation or other methods).
Resnik theorizes that the infant suffers a conflict (virtually life and death) between the pleasurable sensation of breastfeeding and the threat of suffocation, which he/she relates to a pleasant feeling. Resnik believes that the behavior may represent conflicts over separation from the mother, symbolizing both the desire for oral gratification and the fear of remaining too dependent on the mother. "Immobilization and asphyxia contribute to fantasies of feeding, reunion and rebirth”. In his theory, Resnik also considers the eroticization of death as related to separation anxiety. Death is a symbol of "leaving and Returning, Appearing and disappearing, dying and being
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reanimated". A patient of Resnik’s described a "smothering by white billows" in early childhood dreams. The author does not mention any cases where there was no breastfeeding. There are no references to autoerotic asphyxiation in bottle-fed babies in the review.
Danto (1980) 68 suggest that the perversion reenacts (on a unconscious basis) the male victim´s feelings of emasculation (castration) by his mother (or via the mechanism of displacement by another dominant appearing female) who is seen as a powerful woman who controls her son´s masculinity: if he “dies” while he is wearing female attire symbolically and on a fantasy level his (unconscious) linkage is that it is his mother who “dies” (i.e. is put to death). In Danto´s view, the fantasy creator identifies with the victim.
In analyzing 177 cases of death from autoerotic asphyxiation in Canada, Psychiatrists Blanchard and Hucker (1990) 50 found that those practitioners who were partially or completely cross dressing at the time of death frequently exhibited two additional practices: anal stimulation with dildos, vibrators or the like, and mirrors or pictures of themselves during autoerotic asphyxiation episodes that triggered death. It is well known to pathologists that transvestite sex typically employs a lot of time contemplating their feminine appearance in mirrors.
Gutheil (1954) 69 called this tendency the "mirror complex". Both authors report clinical experience with some transvestites that stimulate themselves anally while masturbating, and this activity is accompanied by the fantasies that their body is that of a woman and their anus a vagina. Blanchard (1989) 70 coined the very appropriate term of "autogynephilia" to refer to the erotic excitement that a man feels in seeing an image of himself as a woman. Blanchard's findings confirm Danto's in the sense that the autogynephilia and inserting objects via the anus within the context of autoerotic asphyxia are a way of killing the woman who controls their masculinity. In other words, the castration complex postulated by Resnick above.
Cowel (2009) theorized that in fully developed autoerotic asphyxia, the male enactor assumes the role of a willing- or unwilling- sacrificial “victim” of a female who
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is perceived as being imperious and indifferent to the victim’s struggle to comply with her fantasized demands. For the author, the autoerotic asphyxia can thus be understood as a reenactment (or “acting out”) of powerful states originally related to a female (mother or surrogate). This “plot”, dimly understood if at all by the reenactor, may also represent a symbolic death for lustful thoughts and guilt inducing masturbatory behavior (i.e., punishment before pleasure). In “surviving” the play –acting death ritual, the individual emerges, time after time, sexually gratified and physically intact with a sense of relief, triumph and contempt/resentment (i.e., “you think I have died for you, but actually I killed you”). 71
The author suggests that autoerotic asphyxia involves a desire for control over the anxiety of life versus death: the closer the reenactor approximates, yet cheats death, the greater the sexual excitement. For him: “it is indeed a curious state of affairs that the reenactor is the producer, director, choreographer, judge, actors and witness in his or her unique, personalized drama”. In essence the autoerotic asphyxia reenacts a “life story” of unmanageable childhood trauma conflicts. In psychoanalytical Freud´s view, the repetition would be a compulsive but futile attempt to resolve those conflicts.
As we will see this description and Resnik's postulates are consistent with the ordalic behavior defined by Charles-Nicolas and mentioned by Le Breton 72 in his sociological theories of risk confrontation.
5.2 SOCIOLOGICAL VIEW: THE ORDEAL OR THE RADICAL CONFRONTATION WITH DEATH
The trial by ordeal or judicium Dei was in a legal practice that lasted until the late middle Ages in Europe. It was a procedure based on believes that God would decide the guilt or innocence of a person or a thing (book, work of art) accused of sin or breaking the law.
The practice was related to fire where the accused would hold a hot iron or put his/her hands to fire. Sometimes the defendants were subject to a Middle Age version of
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water boarding. If he/she survived or was not too hurt, it was understood that God had considered him/her innocent and should not receive any punishment. In this sense ordalic behavior makes reference to trial by ordeal which "puts life up to God" that is, the victim risks his/her life voluntarily.
In physical activity or high-risk sports, symbolic play with death is more or less defined and easily understood. However, it is not easy to understand the desire to play with death, of entering its territory. That is the foundation of the ordeal, i.e. a form of deliberate play with death. In the author's words: “There is no intention of actually dying, but rather of testing out their personal determination, of finding an intensity of being, a moment of supreme being, giving voice to a cry or expressing suffering, and sometimes all this is intermingled with a quest which often only takes on a meaning in the aftermath of the event.” 73
For Le Breton, assuming a risk taking is ambivalent in that it is a lucid act of willpower, of asserting self-confidence, which distinguishes it from outright blindness or a firm will to die. It entails an evaluation of the actor’s own resources as he/she leaps into action; a calculation, perhaps intuitive, of the probability of success, but it also relies on a wager that mixes in a rather confused way the ability of the actor in this kind of situation with the perception that he/she has of his own "luck", his/her particular talent to escape the worst.
The author quotes an interesting example of swimmer Guy Delage, well known for having crossed the Atlantic Ocean swimming 10 hours a day for two months from Cape Verde islands to the Caribbean. For the author, Guy Delage typifies the passion for risk shown in these testimonies and is a clear example that abounds in which followers describe that the extent of the symbolic confrontation with death is a commonplace of which they usually come out winners. "Death is a magnetic pole for me ... I learned to live near her, to face her, very often included it as a plausible hypothesis in my projects ... Of course, there's a game ... I like to touch death without ever reaching it; this game gives me a subtle extreme pleasure. This permanent vision of what it is to escape her releases adrenaline flows... therefore, pleasure”. Before jumping in to gain the other side
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of the Atlantic by swimming he wrote postcards to friends, "The Atlantic, will it allow me to get to the other side? If not, my relatives will receive on this insignificant piece of paper my last affectionate thoughts towards them”. The most interesting thing in this example is that Guy Delage rejects any suicidal intent. "I love life terribly. I know every corner, all the possibilities. I seek to broaden the fields of the wrappings of my life, turning it like a bubble, inflating it to the limit of its ability without letting it explode. The game is to come within setting off the explosion without actually having it go off. My extraordinary experiences allow me to enjoy a life of intense passions”. 74
The concept of ordalic behavior and its application in forensic pathology at the time of defining the manner of death is interesting. In some academic settings the determination of manner of death in risk behavior such as autoerotic asphyxiation, Russian roulette and heavy drug use has long been discussed. Some forensic pathologists and Latin American psychiatrists believe they are a form of suicide as they are considered from some point of view "self-destructive behavior." In some cases, the consensus has been to label this type of violent deaths as indeterminate. But understanding the principle that ordalic behaviors is a means of defying death and beget some kind of satisfaction is important. Deaths of this kind in my opinion should be treated as accidents.
5.3 CONFRONTATION TO RISK IN ADOLESCENCE
For Le Heuzey, 75 the most dangerous games (including choking) are integrated within the field of risk taking behavior which mostly occurs in adolescence, precisely where variety of behaviors become evident ranging from the practice of extreme sports to alcohol and drugs, driving a motorcycle without a helmet, racing cars and unprotected sexual encounters. During adolescence, “thrill–seeking” behavior is probably the norm. In this respect the findings by Braush et al. 76 as documented by the department of psychology at Illinois in 2011 are interesting. She found that adolescents who practice self-inflicted asphyxia are more likely to experience other risk behaviors than those who do not practice them.
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Le Hauzey 75 explains these behaviors by different mechanisms:
1. Search the new : The young tend to seek out new experiences outside of everyday life, to leave behind the routines of childhood and to experiment forbidden sensations.
2. Search or giddy thrills: The author describes the notion of pleasure as being very much a part of the scarf game. One of his patients notes: "When I play I feel fine, I feel no more pain, I suspend myself and everything is happiness." Some teens recognize the perception of sexual pleasure when they practice the game alone. For others the pleasure is given by the loss of consciousness with its hallucinatory sensations. According to sociologist Le Breton in his book "Passions du Risque" 71-73 mentioned before, these risk confrontation experiences unfold in four successive phases:
a. Risk taking (vertigo): In this stage the adolescents are aware of the danger. They discover that death can be tested and surpassed. So in this game they can overcome their anxiety of the unknown, and instead of being passive in the face of this anxiety, the teenager will on the contrary provoke and overcome it. This preliminary stage is a way to prove to themselves and to their peers that they are capable of doing anything to confront danger.
b. The confrontation : They do not measure themselves against another individual but only against themselves. They are their own adversary and can overcome fear and control their body.
c. Whiteness : The third stage for some young people is to experience their own demise. It is the state of turning in on oneself, or that of absence or coma. At this stage the experience is so strong that the youth is in a situation of loss of consciousness or disappears symbolically. According
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to some young people’s reports, this experience may be related to Near Death Experiences (NDE). The feeling of depersonalization and elevation are commonly described in asphyxia games.
d. The rebirth -survival : Surviving is a victory over oneself and over death. This is the ordalic aspect of these behaviors. As explained above, ordalic practices related to defying death to give more meaning to life and to validate oneself before one’s peers. For the author it is a form of death and resurrection. The boundary between risk behavior and suicidal behavior is often vague: a life-game, flirting with death or definite intention of ending life. One of Le Heuzey’s asphyxia participant patients says: "It is the danger, the risk that gives me pleasure." From which can be deducted that in these cases death is not the ultimate goal, instead, death is an instrument, the means by which the individual restores his/her sense of identity.
3. Addiction Drug-Free: The pursuit of the sensation of pleasure and vertigo once experienced leads to repetition of the game. The practice then evolves as true addictive behavior: there is a need to play more frequently and increasingly take more risks. Anxiety appears if the game cannot be repeated. Author Michel even speaks of a form of "risk addiction" and the emergence of some degree of dependency.
4. Search for recognition by peers : To belong to a peer group one needs to pass certain trials. This need to be recognized by others, to be admitted into the group, leads young to accept putting their lives at stake. Courage is a characteristic associated with the strongest and often the fact of being stronger means being able to torment the weak and thus be recognized and respected by others.
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5.4 CHILDHOOD ROPE SYNDROME
The term was coined by Rosenblum 25 appears in 1979 to explain a possible link between these practices with what he later called "Adolescent sexual Syndrome". While not referenced by this name in search applications or in articles, there are a number of publications that speak about accidental hangings in children and adolescents. These items were found by cross-referencing other articles described in the methods section.
In the United States Clark et al. (1993) 77 conducted a review of all hangings in children in Marion (Indiana) and Franklin (Ohio) counties during a period from 1985 to 1990 for ages 2 to 13. While the paper documents five cases of clear accidental hangings among preschoolers and three clear suicides, it describes a group of 4 cases in which the manner of death was classified as undetermined. All these cases were males, ranging from 6 to 12 year olds, who were found inside their rooms fully clothed and had no history of depression or dysfunction of the family. The practices were held in closed quarters or in moments of parental absence, which suggests a context of premeditation and secrecy.
In the United Kingdom Nixon et al (1995) 78 reviewed the deaths by suffocation, choking and strangulation in England and Wales between 1990 and 1991. The authors used the information available at the Office of Population Censuses and Surveys (OPCS) and reviewed in detail records of HM coroners' offices and death certificates. The author classifies accidental deaths by hanging in two groups: the first from 1 to 7 years which correspond to deaths with ligatures around the neck with ropes or clothes in the house and a second group of 8 to 14 year olds that were classified as "self Initiated hanging" where the child was involved in some kind of game. Only one case is classified as autoerotic asphyxiation because of the characteristics of the scene. During this period the study describes a total of 21 cases of involuntary youth hangings between 8 and 14. All the victims in this group were male. In the first group the proportion male / female is 3: 1. It is noteworthy that the authors have documented a high number of cases (21) in the population under study in such a short period (only two years).
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Also in the United Kingdom, Wyatt et al (1998) 79 makes a retrospective study of hangings of children in Scotland over a period of 12 years. He reports a total of 12 hangings of which half are classified as accidental hangings. Within this group he describes cases between 4 and 14 year olds, two with full suspension and 4 with incomplete suspension. Five of the 6 cases of accidental hangings apparently are related to “experimental behavior” involving the use of ligatures around the neck. All cases including non-accidental were carried out in absence of parents and it is very striking that 10 of the victims are male.
Personally, I do not think these findings strange. I agree with Rosemblum in as much as there are children (mainly male) who participate in asphyxia practices in order to find some type of pleasurable sensation, and it is common. The suspension with curtain ropes or other ligatures is a common practice. Male children also find pleasure in other asphyxia maneuvers such as confinement in small spaces, games with bags over their heads and even extrinsic compression of the thorax.
5.5 PART OF THE SAME SYNDROME
According to the literature reviewed, the epidemiological studies, psychoanalytic theories and the results of this study that show how the victims, whether adolescents and adults, of both asphyxia games and autoerotic asphyxiation are predominantly male, use same method and type of asphyxia, concur as to place of occurrence, share elements of compulsivity, premeditation and secrecy associated with the search for some form of pleasure as well as share several risk factors associated, suggests the existence of a single syndrome that develops into a model of development in stages or phases. In each it becomes evident that there exist conflicts in the oral development leading to "childhood rope syndrome" and this in turn evolves into the practice of asphyxial games associated with masturbation during adolescence, then to an adolescent autoerotic syndrome and eventually ends up in a flowery sadomasochistic bondage adult syndrome.
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In line with that suggested by Rosenblum 25 , who suggested a lineal model (excluding asphyxial games) it is not necessary for an individual to develop the entire sequence as there may be entrance and exit doors at any point of the sequence. One may be defined as the moment in which the conduct is adopted, which can occur during childhood or pre-adolescence as rope game (childhood rope syndrome); in preadolescence as an asphyxial game later as associated with masturbation or during adult life as part of a complex sadomasochistic bondage syndrome.
Exit may be defined as the time when the behavior stops either by accidental death in the case of children and adolescents, by resolution (spontaneous or through psychotherapeutic intervention) or accidental death in adults or through the suicide.
The essence of the developmental model is that evolution is based on behavioral adaptation to psychosexual, physical and social reality needs. According to Rosenblum 25 , basically, the person develops deviant sexual needs as a response to intrapsychic conflict, and so is able to then adapt to the reality imposed by physiological behavior (asphyxiophilia) or die in the process. The form of adaptation is in turn limited by their environment or social realities (e.g., gets a partner involved and protects him in his paraphilia). The degree to which this adaptation succeeds or fails, both physiologically and emotionally will determine whether the person lives or dies. In other words if the individuals misjudge their physical tolerance to asphyxia, cannot find a partner to protect them or fall into depression, they die. The failures in the management of physiological needs (e.g. extended compression of the neck to prolong the pseudo halucinant effect) lead to accidental death, and failure to meet emotional needs (e.g. develop into a picture of depression) end up in suicide.
Under this scheme just as many individuals do not fully develop the sequence and may enter at any stage, there will be individuals who develop through all stages consecutively.
Based on Rosenblum’s principles, I propose a new modified linear sequential model of four stages:
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1. The Childhood Rope Syndrome
2. Asphyxia games associated with masturbation
3. Adolescent Autoerotic Asphyxia
4. Adult Autoerotic Asphyxia (fetishist / bondage Syndrome)
This model includes both the choice of sequencing of the four stages and the choice of various in/out gates at each stage. Exit gates are still open through resolution (either individually or through treatment or psychotherapy) or death understood as a failure of mechanisms to adapt.
Entrance to the first stage, Childhood Rope Syndrome, would be highly influenced by the conflicts in the oral phase of psychosexual development. Visual influences cannot be ruled out because the literature has reported that children will try these practices after seeing hangings in films, television programs or in more recent times, influenced by websites. Religious influence cannot be ruled out either. I will discuss these later. I do not believe that the majority of deaths related to accidental hangings in children occur in males and that the fatal event has taken place in the absence of parents is only a coincidence. In my opinion the rope childhood syndrome is a component of the game as is getting some form of pleasure. However it is not overtly sexual. Perhaps practitioners act as inductors or diffusers of these practices to school-age peers. At this stage the ordalic and risk behaviors existing in adolescence are not present.
Several practitioners at phase 1 who adapted to Rope Childhood Syndrome and did not did accidentally die will move on to include the sexual component in their games by the time to reach pre-adolescence and when exposed to certain risk factors will evolve into phase two of the sequence: Asphyxia Games Associated with Masturbation. Some of the practitioners, probably less influenced by conflicts of the oral phase or those who improve their home environment only reach this stage and find an exit at this stage as a resolution (suspension from practice). Others on the contrary will be exposed to new risk factors and evolve to phase three: Adolescent Autoerotic Asphyxia.
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Accidental Suicide Accidental Death Death Death Accidental Depression Death Adaptation 4. Adult Autoerotic Asphyxia Syndrome 3.Adolescent Accidental Adaptation Autoerotic Death 2. Asphyxial Asphyxia Resolution Games Adaptation Associated to Resolution Masturbation Risk Factors Resolution 1. “Childhood Rope Syndrome” Genital Phase Conflicts
Oral Phase Conflicts
Adaptated and modified from Rosemblum s. Faber M. The ad olescent sexual asphyxia syndrome. J Am Acad Child Psychiatry . 1979; 18:546- 558.
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Factors related to both practices are essentially the same as those shown in this paper. Rosenblum and Faber 25 mentioned factors such as exposure to violence and sexual activity in their study of living autoerotic asphyxiation practitioners. The linear epidemiological study carried out by Ramowski et al. in Oregon (USA) (2008-2012) 42,45 among high school students through a survey showed that some factors related the practice of asphyxiation games were exposure to violence, sexual abuse and premature contact with alcohol and drugs. The epidemiological study of Dake et al. 43 also among school practitioners of asphyxiation games (2010) identified exactly the same variables as well as mental health issues. Shankel and Carr (1956) 80 , Rosenblum and Faber (1979) 25 and more recently Eber and Wetli (1985) 81 mentioned dominant and / or punitive mothers, academic problems and absence of the father as common features in adolescents practicing autoerotic asphyxiation. Dake et al. (2010) 43 also describes homes with no father and academic problems as a factor associated with the choking game.
However, in this model not necessarily all the teenagers involved in these practices come from phase one. A significant number enter directly through the pre-teen and teenager door. Conflicts in the genital phase of psychosexual development as well as history of sexual abuse would have the greatest weight as risk factors.
Psychiatrists Friedrich and Gerber (1994) 82 recounted in great detail 5 cases of teenagers (still living) involved in asphyxia autoerotic (all male) and identified common factors. Again physical abuse, sexual abuse and further strangulation history, risk taking behavior and learning through a friend are mentioned. The last three components are clear in asphyxial games: they are a form of strangulation activity, they are learned behavior and as explained above correspond to a risk taking behavior. Additionally the first two (physical abuse and sexual abuse) may explain the conflicts in the genital phase of psychosexual development and promote direct entry in adolescence. Studies of Dake (2010) 43 and Ramowski (2012) 45 , also identified drug use and gambling as risk behaviors common among practitioners of the asphyxia game.
If to this model the sociological concepts of Le Breton 73 about ordalic behavior and risk behaviors that are manifested strongly in adolescence are added, it bears to posit
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that young people exposed to the factors of intrapsychic conflict mentioned above and in contact with the asphyxial game while testing the effects on the brain, make this their favorite tool when challenging death.
The severity of the factors affecting psychosexual development (mainly related to sexual abuse) will depend on the speed in developing through the sequence, i.e. the speed of moving from one game associated to masturbation (phase two) to the Adolescent Autoerotic Syndrome (phase three) of the developmental model. This would explain the findings of this study where sophisticated components of fetish and bondage appear at ages are as young as 12.
From the model it is understood that contact with the choking games or its occasional practice would not necessarily lead to the child developing the asphyxia games associated masturbation or subsequent Adolescent Autoerotic Syndrome. As mentioned in the theoretical framework many of the children agree to participate in the games as a form of being accepted to the group in response to peer pressure. In this situation if the adolescent has no associated risk factor (e.g. no changes in any phase of psychosexual development), the child will tend not to repeat the practice and if he/she does so it will probably be repeated in groups with the company of friends. Recall that epidemiological studies showed that most respondents, practitioners of games asphyxiation, performed them in the company of another person. The real point of entrance is where the practice becomes single, repetitive, and clandestine and integrates the pleasure and / or sexual (masturbation) components.
This brings to mind that in his epidemiological study Macnab (2009)41 showed that all women who took part in the game did so in the company of another person and that those who admitted to being regular practitioners mostly were men and did so while being alone. Ramowski’s study 45 showed that at least 64% of those men practicing the game repeated it. This result would explain what has been documented in the present study where the vast majority of victims of both autoerotic asphyxiation and asphyxiation games in adolescents are males. Since men tend to play the game repeatedly in solitary plus the additional sexual component, the group as a whole is more predisposed to failure
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in the physiological adaptation to asphyxia and therefore show more accidental deaths. Recalling the castration complex as postulated by Freud and Resnick 3, from the psychoanalytic point of view, it maybe posited that men are somehow more prone to exhibiting disorders of the oral phase and because men are more exposed to risk factors such as exposition to violence, sexual activity and substance abuse, they are in fact more vulnerable to develop the syndrome. All epidemiological studies support the theory of sexual motivation in these games played out repeatedly and in solitaire; as in Macnab (2009)41 , Dake (2010) 43 and Ramowski (2012) 45 who identified sexual activity as a risk factor directly related to the playing of games of asphyxia.
While death as a result of asphyxia games practiced in groups is a potential risk, it rarely occurs according to the results of present study. The probability of death increases with solitary, repetitive and clandestine practices associated with the pleasure component. If we recall the sexual response cycle (SRC), it is hypoxia and sexual fantasy which act as cortical desinhibitors causing compression of the neck to be dangerously prolonged and affect the sense of perception to the point where the rescue mechanism provided will not be activated.
Somewhere between the third and fourth the choking technique and the rescue measure swill tend to become more sophisticated (the ordalic component of confronting risk and defying), and other paraphilias, especially fetish / transvestism , bondage and sadism / masochism will also appear. The physiological and emotional adaptation will determine whether the person survives. As mentioned above, according Rosemblum 25 emotional adjustment at this stage is limited by the environment or the individual's social reality. In this sense depending on whether the person finds a partner to participates in asphyxial maneuver, the risk inherent in the practices will be reduced. On the other hand emotional security give by having an accomplice will prevent the victim from falling into depression. Given the above step 4 is not necessarily autoerotic and can become erotic asphyxiophilia involving a second person. Exit doors are again individually resolution or as a result of treatment, (psychotherapy - psychotropic drugs) or death: accidental if there
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is a failure in physiological adaptation, or suicidal if there is a fault in emotional adjustment.
Supporting the “developmental model” Curran et al. (1980) 83 claim that each individual develops his or her own autoerotic asphyxia techniques, which become embellished and elaborated over time. As the same as other investigators, they found that to one degree or another, fatal cases presented a characteristic profile syndrome. They described stages ranging from early “sex play” (asphyxia games) to complex suspension activities in later adolescence and adulthood, including nudity, and, unlike females, with paraphernalia consisting of mirrors, pornography, bondage and fetichist/transvestite articles such a female clothing. They did not consider asphyxia games as a failed form of autoerotic asphyxia but rather a simpler, less elaborate, non ritualized activity without the need for escape mechanism, pornography, and cross-dressing, which are typical of fully developed autoerotic asphyxia, yet their description of stages suggest a possible link between early and later forms and then supports the developmental model propose firstly for Rosemblum 25 .
Another interesting study that supports the developmental model as mentioned above, was carried out by Blanchard and Hucker (1991) 50 in Canada. They took a total of 117 cases of autoerotic asphyxia victims between 1974 and 1987 in the provinces of Alberta and Ontario in Canada. Multiple regression models for bondage and fetish variables / transvestism versus age through correlation coefficients were used. The results showed that as age increases the proportion of exhibiting behaviors such as bondage or fetish / transvestitism or both increases significantly. The data from the study show that older practitioners of autoerotic asphyxiation exhibit a higher probability of involving transvestitism and bondage in their practices. This finding is consistent with the notion that practitioners gradually developed increasingly complex masturbatory ritual practices over time and would agree with the concept of adaptation raised in the developmental model.
Previous studies (Hazelwood et al 1983) 6, also showed a large proportion of practitioners of autoerotic asphyxiation simultaneously engaged in one or more
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paraphilia episodes at the time of death. These findings are consistent with the consensus that exists in psychiatric clinical practice on the presence of a paraphilia tending to facilitate the appearance of other ones. (Eg Wilson and Gosselin (1980)84; Buhrich and Beaumont (1981)85, Freund et al. (1986)86; Lang et al. (1987)87; Abel et al (1988) 88. Some authors even posit an association between specific paraphilia and paraphilia that are true syndromes.
Several explanations have been suggested to explain the general tendency of paraphilia to appear in clusters. Abel et al. (1988) 88 hypothesized that the absence negative consequences of their first experience of paraphilia by the practitioner will cause him/her to be less inhibited when incorporating other fantasies about other paraphilia. Bancroft (1989) 89 stresses the tendency of paraphilia to occur simultaneously suggests that the conditions necessary for development of a particular type of paraphilia may facilitate the development of others. He conjectures that this can potentially curb some characteristics of the central nervous system that underlie the individual's sexual learning. This conjecture is equivalent to the notion psychiatric paraphilia diathesis.
In reviewing the psychoanalytic literature there appears reported a case consistent with this model and the concepts previously reviewed. Eber and Wetli (1985) 81 made a detailed description of a patient of his who later died at age 34 during an autoerotic hanging inside a hotel room. The patient reported that his behavior began in preadolescence. From a psychoanalytic point of view the therapist identified conflicts with the mother, narcissistic personality elements and sadomasochistic elements. Two aspects prove interesting. Firstly while being aware of the practice the wife becomes intolerant of compulsiveness of the aberration, so the patient begins to practice asphyxiation in secret in a hotel room. The second point is the patient's identification with Christ's passion and resurrection from adolescence. In the first aspect of the behavior compulsiveness and intolerance of the couple causes a disruption in the physiological adaptation to asphyxia and produces the exit sequence of accidental death.
The second point which is the description of the death and resurrection of Christ fits, in my opinion, the concept of ordalic behavior, more precisely the stages of
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whiteness and rebirth proposed by Le Breton 72 in his theories of confrontation of risk to which is added a significant erotic component (sadist / masochist). Edelheit (1974)90 speculated that identification with Christ and erotic fantasies related to the crucifixion are almost universal in our culture (at least Western culture). He has found manifestations of this phenomenon in many patients regardless of gender, race and even religious choice. In a case described by Eber and Wetli (1985) 81, he possesses two photographs of the victim involved in erotic practices and the poses are very similar to classical paintings of Christ crucified (e.g. The Crucifixion of El Greco). Hanging can represent Christ on the cross, after which after whiteness (semi unconscious status from compression of the neck) he is reborn almighty, next to God.
Lubin (1959) 91 tells of a preteen patient in whom he shows how the unconscious identification with Christ is a factor in the development of fantasy and sexual behavior. The early fantasy during masturbation of this patient was to have all four extremities tied, then crucified and masturbated violently by a friend. It is to be remembered that the crucifixion is in fact a kind of positional asphyxia. Supporting this view Money (1993)92, suggested that autoerotic asphyxia is probably overrepresented among persons with strict religious backgrounds.
5.6 RISK OF DEATH
In the first and second phases of the sequence death would come almost exclusively from a failure in physiologic adaptation and, as mentioned above, would mean a type of accidental death. It is easy to understand that infants and pre-teens do not understand the physiology or the implications of neck compression. Nor has he/she developed the concept of protecting the neck or some other mechanism to control the compression. This would explain why in cases of children and teens the type of ligature is very basic (in some cases simply a rope in U shape without any knot) and without padding.
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In phase three teens in the model will be better adapted physiologically. They will know the technique, wear more elaborate knots (sliding), used padding and develop a complex rescue measure. Despite this, the majorities of deaths are to be explained by failures in physiological adaptation and thus are accidental deaths.
Medical literature suggests that the practitioners of autoerotic asphyxia are usually depressed adolescents and their older counterparts are more prone to depression. Consequently one can infer that the risk of suicidal instead of accidental death increases with age. Taking into account the processes of adaptation mentioned by Rosenblum 25 , this could be explained by the fact that adults find a partner who protects them while performing the procedure (physiological adaptation) and are therefore less likely to die from unintentional suffocation (accidental). On the contrary, as adolescents and younger adults are more likely to carry out the act alone, they are at an increased risk of unintentional death.
Death in mature and older adults would most likely occur because of emotional maladjustment whether caused by the difficulty of finding a mate who agrees to participate in the perversion, the difficulty of maintaining a one who will accept the compulsive behavior or the loss of such a person. Emotional maladjustment results in a suicide-type exit. It is likely that a significant number of practitioners of autoerotic asphyxiation end up committing suicide. However in the absence of tools such as psychological autopsy is almost impossible to distinguish which suicides may be related to these practices.
My assessment is supported by the findings in the review of the bibliography presented here in which the majority of cases happen among adolescents and young adults. Deaths of mature adults and seniors will be labeled simply as suicide and not be tied to any practices of autoerotic asphyxiation. The study conducted by the CDC in Atlanta comparing the choking game deaths to deaths by suicide in adolescents shows a clear trend of suicide increasing in direct proportion to age.
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A complex and unusual exit door to the model may be in the form of autoerotic suicide, first described by Hazelwood (1983)6 in two cases in which all the Fetish / transvestite paraphernalia accompanied by bondage and masochism but with a clear antecedent of depression and / or existence a suicide letter present at the scene. More recently, Bhardwaj et al. (2004) 93 described a case in New Delhi - India of a 22 year old subject with evidence of fetishism / transvestitism, no apparent rescue measure or protection in the neck and with a history of depression and a marriage described as dysfunctional. Benomran et al. (2007) 94 described the case of suicide in Dubai (UAE) of a 35-year-old man found in suspension in an open area with evidence of masking and bondage. This exit would be unusual only in adulthood in stage four of the proposed model when the individual has achieved a high degree of sophistication in the technology and has developed several paraphilia but flawed in emotional adjustment, so falls into depression and commits suicide.
5.7 LIMITATIONS
One of the major limitations in conducting this study was the small number of articles found for both autoerotic asphyxiation in adolescents and choking games. It is very striking that while the Atlanta CDC reports a total of 82 fatal cases in the period from 1995 to 2007 in the United States, 8 only 6 cases appear reported in the literature. Two of them were not categorized as games but as adolescent sexual asphyxia.
As mentioned earlier references to choking games are very recent (much of them in the last decade) and it is possible that there is still no widespread knowledge of this practice among health professionals working with adolescents (pediatricians) and among those addressing related deaths (Forensic pathologist). In this regard McClave et al. (2009) 95 conducted a survey of pediatricians and general practitioners and found that only a third of the professionals had knowledge of the games and did not recognize that practice of choking games could be an activity potentially life threatening to adolescents.
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In the same study, only 52.3% were able to identify 3 of 10 clinical warning signs that commonly described these practices.
Deaths reviewed by Andrew (2007) 64 showed two cases where the initial conclusion was suicide. It was only thorough subsequent information provided to the medical examiner that the manner of death was modified. In the first case the mother found e-mails referring to the practice of the games and in the second case the practice came to light after review by the Child Fatality Review Team. Articles were found to be minimal or non-existent when reviewing published articles of fatal case descriptions of personal, family and the behavior of the victim. The descriptions were limited to the description of characteristics pertaining to the discovery of the body and findings regarding internal examination at autopsy.
When conducting a survey among 28 coworkers of the group practicing forensic pathology autopsies daily at the National Institute of Legal Medicine and Forensic Sciences in Bogotá (Colombia), only two colleagues had heard of the practice. The lack of knowledge about these practices on the part of researchers and police who arrive at the death scene as well as the professionals who perform autopsies coupled with the failure to integrate the personal history of the victim to their findings, cause the deaths to be wrongly labeled as suicides or in some cases as undetermined deaths.
A review sociological, psychiatric and psychoanalytic literature was essential in this study. It revealed close links between asphyxia practices and disorders in psychosexual development and their integration with sociological components as well as theories of confrontation with risk in adolescence.
I was struck by the very low number of publications in journals of psychiatry and psychoanalysis regarding regular practitioners of autoerotic asphyxiation. One explanation put forth by professionals is that these patients usually do not consult any therapist. When they do consult, they tend to not return for further psychotherapy. There are also ethical limitations to not publishing these cases in scientific articles.
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The last limitation found was that in the series of fatal cases autoerotic asphyxiation reviewed, researchers excluded choking and asphyxia games as well as those of autoerotic asphyxiation. In many of the articles the existence of cases with elements of both practices is tacitly suggested -i.e. reference to asphyxial games and partial nudity but without the paraphernalia specific to pornography or autoerotic death due to paraphilia. The authors did not consider most of these cases. To my mind this is a bias that represents one of the causes that has prevented or limited research in this direction. Only psychiatrists who analyze cases and study the distortions in psychosexual development in living people based on psychoanalytic theories suggest the existence of a link between the two practices and publish their findings in scientific journals.
5.8 RECOMENDATIONS
For future research in this area I suggest a detailed review of reports and series of cases of hangings in children, preadolescents and adolescents. The results of this study and several of the articles reviewed strongly suggest that some of the cases initially labeled as suicide and many labeled as accidents or undetermined deaths are related to games or even asphyxiation autoerotic asphyxiation.
In cases where psychiatrists and psychoanalysts have addressed the issue of autoerotic asphyxiation but have not published their findings in scientific journals, information could be obtained through personal communication to explore their experience in each case, omitting of the patient's identity. This would preserve the ethical principles of confidentiality and disclosure. The psychoanalytic view is essential for a better understanding of these behaviors and to conduct any investigation in the future.
Regarding fatal cases, it would be helpful that during the visit to the scene of the crime a multidisciplinary team that included the research coordinator (State of Local attorney - coroner), a pediatric professional, psychologist or psychiatrist, a social worker, as well as a forensic pathologist member of the family and the school were present. The team would be responsible for identifying potential risk factors (exposure to physical
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violence, sexual abuse, substance abuse, gambling, etc.) as well as exploring any contact with choking games. In some cases it might be necessary to return to the scene to try to identify related evidence while bearing in mind the possibility of some overlooked sexual component. In all cases the psychological autopsy report should be shown.
Future studies can be done using the research methods used by the CDC in Atlanta (LexisNexis) where the likely event may be located through press releases and then corroborated by the official reports of the death through the office the medical examiner or competent authority by country. Another source of information may be the web sites of "choking game awareness" which report related deaths (also used in the study by CDC Atlanta). In all cases it is essential to corroborate the information with the official report of the case, including the results of the autopsy.
Also awareness of these practices among health care professionals should be promoted, especially among those who are in contact with the exposed population -i.e., pediatricians, nurses, psychologists and child psychiatrists as well as school authorities. Health personnel should be alert to identify warning signs that indicated the existence of behavior. In this regard they should pay attention to pictures in recurrent epileptic manifestations 96-97, syncope 97-98, encephalopathy 99 and retinal hemorrhages 100-101, which are scientific references associated to the practice of asphyxial games in living patients.
It is also important to disseminate such information among police and research personnel, and among physicians and pathologists who practice medical legal autopsies. Regarding the dissemination to parents or the media, it should be transmitted in a prudent and scientific manner to avoid generating mass hysteria, as demonstrated in the Toblin study (2008) of the CDC of Atlanta when overexposure by the media and misrepresentation of information ended up in the appearance of cases in cluster. Parental supervision is particularly important for young people who engage compulsively and alone in this activity 101 . Future research should focus on parental guidance to provide both supervision and education during this complex stage of life.
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